They wade through rough waters and climb steep terrain, walk for kilometers and bear the rains – the undaunted, the persevering and dedicated Accredited Social Health Activists (ASHA workers) work relentlessly towards raising the bar of the Indian public health system.

A news article in the Asian Age showed how in the absence of roads, dedicated health workers like Abaron Bibi ferry the ASHA team across the wetland in makeshift rafts, in extremely hot and humid conditions in Golakganj, Assam to ensure immunization of women and children in the community.

Similarly, ASHA Meena Kumari from Pini traverses hilly terrains of Himachal Pradesh to carry the vaccine carriers from the cold chain point of Jari Community Health Centre, 40 km away from Malana to ensure immunization in the community. Her role extends beyond immunization and health literacy since there is no Alternate Vaccine Delivery (AVD) possible due to the hilly terrain. Meena covers the 40 km distance, partly by public buses and partly on foot.

In Alirajpur, Madhya Pradesh, located in the backwater zone of the Narmada river a boat ambulance called ‘JananiExpress is the only way to deliver health services. Auxiliary nurse-midwifery (ANM) worker Preskila Parmar has been serving this area almost entirely by herself for close to two decades now. She vaccinates more than 5,000 people in the five villages that she covers daily. In the complete absence of public transport in the region, she covers the distance running into several kilometers on foot.

In Numbers

The recent figures released by the Ministry of Health and Family Health showed that the immunization rate went from the long-prevailing 1% to 6 %, the highest increase in a decade under Mission Indradhanush, which was launched in December 2014, which the aim of achieving complete immunization by 2020. The program is designed to provide life-saving vaccines to all children across the country free of cost to shield them against deadly tuberculosis, diphtheria, pertussis, tetanus, polio, hepatitis B, pneumonia, meningitis, measles and rubella, Japanese encephalitis and rotavirus diarrhea.

A total of 3.4 crore children and 87.1 lakh pregnant mothers have been vaccinated so far. Many attribute this success rightfully to the Auxillary Nurse Midwifery (ANM) and ASHA workers who are real heroes who have made this possible by reaching the remotest of villages to make life-saving vaccines accessible to pregnant women and newborn infants in the country. They make immunization possible even in the most far-flung pockets in India.

Not only has this workforce contributed to the public health care system in providing mass-scale immunizations but they have also played a key role in boosting institutional deliveries and bringing down mother and newborn deaths. A study published in Volume 4 of Primary Health Care in 2014 reads “According to a report released by the State Institute of Health & Family Welfare, Rajasthan, ASHA workers have brought an increase of 80.7 % in institutional deliveries.

But Are The ASHA Workers Treated Well?

It is unfortunate that this 900,000-strong woman workforce in the health sector – the ASHA workers who play the crucial last link to India’s rural healthcare delivery system — enjoy no fixed salary or social security.

All states have different payment methods for these grassroots health care providers. Barring some states, the ASHA workers do not get fixed salaries, but incentives for every work they do. Their take-home pay depends on the number and kind of activities they engage in throughout the month. In all, there are 43 listed activities they can work on depending on the requirement of the population covered. They range from a maximum of Rs 5,000 for administering medicines to drug-resistant tuberculosis patients to just Rs 1 for distributing an ORS (oral rehydration solution) packet. ASHA workers mostly earn more through the more common antenatal care (Rs 300), institutional delivery (Rs 300), family planning (Rs 150), and immunization (Rs 100).

At the end of the month, they get a combined sum of these incentives based on the services provided, which in a lot of cases does not add up to even the minimum wages for a skilled laborer (Rs 16,962 in Delhi).

But across the states, the complaint is the same – the ASHA’s are generally paid very late, underpaid, lack the necessary skills because of little training, and have poor motivation to excel at their jobs. This is slowly translating into growing absenteeism and vacancy rates in certain states. Even the Ministry of Woman and Child Development is struggling to retain and hire ASHA workers.

Increasing Resentment Reported From Across India

The voices of protest from this underpaid class of workers have been growing in recent years. In January last year, hundreds of ASHA workers staged a protest demanding a hike in wages and fixed working hours with retirement benefits in Kalaburagi city in Karnataka. They demanded regularization in services coupled with minimum wages of Rs 18000. They were being paid Rs 3000 a month. CITU and other trade unions also organized at least two mass-scale protests of ASHA workers from across India in New Delhi in 2018.

Even in November 2017, thousands of ASHA workers along with Anganwadi and mid-day meal workers traveled to the Capital to participate in a three-day protest. The agitation was an extension of a protest that happened the same year in August when ASHAs from 11 states marched in protest in the Capital demanding fixed salaries, higher incentives, and inclusion in social safety schemes such as pensions.

Step In The Right Direction

While the BJP Manifesto promises to extend the benefits of the Ayushman Bharat program to the ASHA and Anganwadi workers, irrespective of their classification under the relevant 2011 census, the Congress manifesto promises a living wage to healthcare workers, not just minimum pay. “Para-state workers like Anganwadi workers, ASHA workers, and other such groups form the backbone of the public service delivery system. We will increase funding for the relevant programs and work with state governments to ensure that they are paid more than minimum wage and all arrears are paid immediately. In addition, we will expand the ASHA program and appoint a second ASHA worker in all villages with a population exceeding 2500 persons,” the manifesto says. While these are promises made in the election fanfare, what will be crucial is that how many of these promises actually translate into action.

Written by – Jaya is an award-winning journalist, with rich experience in public affairs and storytelling. With over 13 years in both media and public relations role, where she has worked with development sector organizations and government in equal measure, she also has a demonstrated history of working as a health and social beat reporter in the newspapers industry. Jaya is a strong, dynamic and innovative media and communication professional with an MS in Journalism Research focused in Communication and Media Studies from E.W. Scripps School of Journalism, Ohio University, Athens, USA and an MA degree in Comparative Literature, Jadavpur University, Kolkata.